临床医生诊疗现场信息需求现状的初步研究

Exploration of Doctors' Information Needs at the Point of Care

目的探索在医疗信息化背景下,医生诊疗患者过程中的信息需求特点,以帮助找到对策,提高医疗质量。方法采用问卷调查结合半结构化访谈调查北京大学两家附属医院272名住院医生。结果医生工作强度高,信息需求大,综合医院门诊医生平均每半天看30位患者;在诊疗过程中,综合医院医生56.1%每天出现≥6次信息需求。这些信息需求最多出现在制定医疗方案阶段;对于两医院的医生,网络信息资源也是一个重要信息获取途径;医生希望信息资源具有信息权威准确、及时更新,载体方便携带、随时可查询及结合临床实际、诊疗方案实现常规化等特点。结论医生在给患者看病过程中普遍存在信息需求。移动医疗、临床路径结合循证医学有很强的应用前景。

Objective To explore the information needs of doctors at the point of care under the background of medical informatization. Method Investigating 272 doctors from two affiliated hospitals of Peking University by questionnaire and a semi-structured interview. Results Workload of doctors is intensive. A doctor sees 30 patients per half day. There are more than 6 times of information needs at the point of care per day for 56.1% doctors from the general hospital. Doctors need more information during making medical plans in their workflow. Web is becoming an important information re source. To be authoritative, accurate, timely updates, convenient to carry and inquiring at any time, practical and routinized is the characteristic of ideal information resources. Conclusion There are lots of information needs at the point of care, Mobile health or ctinica pathway combined with evidence-based medicine has strong application prospects.